Keeling, Doris Qa..... IF)\ f 3c-i
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Doris Keeling Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/24/2022 89 Years War or Dates
E,. Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
a Manner of Death El Natural Cause Accident Homicide ❑Suicide Undetermined riPending
V Circumstances Investigation
EMedical Certifier Name Title
�] Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
,Town or Vi ll5e Ce 5601 229
Burial Date Cemetery,Crematory or Facility Name
Addre2022 Pine View Creatory
Entombment Address
aCremation Queensbury Town,New York
Donation
goRemoval Date Place Removed
and/or and/or Held
N Hold Address
0
O. Date Point of
N OTransportation
a by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
5 Address
Q
W
0. Permission Is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/26/2022 Registrar of Vital Statistics Moran AroGii(`� n 3'•if1n9
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
giu -Z Date of Disposition �12g lit Place of Disposition „� a. ,i..__
2 (address)
W
yIt (section) (lot number) (grave number)
4
8 Name of Sexton or Person in Charge of P ises r7 L `.l it
z
(Pie a print/
Ill Signature Title ( 1i1.10 .
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
II
-
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# ,